Cork University Dental School and Hospital - Doctoral Theses
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Item Perceptions of Class II malocclusions(University College Cork, 2024) Brosnan, Sinead; Millett, DeclanAims • To investigate if Oral Health Related Quality of Life (OHRQoL), self-esteem and perception of orthodontic aesthetic treatment need differ in children/adolescents with Class II division 1 malocclusion (II/1M) compared to children/adolescents with Class II division 2 malocclusion (II/2M). • To investigate if perceived OHRQoL, perceived self-esteem and perception of orthodontic aesthetic treatment need differ in parents of children/adolescents with II/1M compared to parents of children/adolescents with II/2M. • To investigate if OHRQoL, self-esteem and perception of orthodontic aesthetic treatment need are associated in children/adolescents and their parents, separately and across II/1M and II/2M groups. • To investigate if family impact differs for children/adolescents with II/1M compared to those with II/2M. Materials and Methods Following ethical approval, 240 individuals were invited to participate, 120 children/adolescents aged 10-16-years (60 with II/1M and 60 with II/2M) and 120 parents. Subjects were recruited from treatment waiting lists in a publicly funded orthodontic service. Informed consent/assent was obtained from each child/adolescent and their parent. Children/adolescents completed a generic (Child Oral Health Impact Profile, COHIP) and a condition-specific questionnaire (Malocclusion Impact Questionnaire, MIQ) to assess OHRQoL, a self-esteem questionnaire (Child Health Questionnaire- Self-Esteem component, CHQ-SE) and self-assessed orthodontic aesthetic treatment need (Index of Orthodontic Treatment Need- Aesthetic Component, IOTN-AC). A parent of each child/adolescent completed the parent version of COHIP, assessed the family impact of their child’s oral health (Family Impact Scale, FIS), completed the parent version of CHQ-SE and rated their child’s orthodontic aesthetic treatment need (IOTN-AC). Demographic and clinical variables were also recorded for each child/adolescent which included age, child/parent gender, socioeconomic status (SES), caries, dental trauma, overjet, overbite, severity of crowding, as well as IOTN both dental health and aesthetic components. ANOVA was used to investigate associations of OHRQoL, family impact and self-esteem between II/1M and II/2M groups. Perceived orthodontic aesthetic treatment need was compared between II/1M and II/2M groups using ordinal logistic regression models. P < 0.05 was considered as statistically significant. Results In children/adolescents OHRQoL, self-esteem and perception of orthodontic aesthetic treatment need did not differ significantly between malocclusion groups (MIQ p = 0.1480; COHIP p = 0.8067; CHQ-SE p = 0.9505; Child IOTN-AC p = 0.8987). There was also no significant difference in parent-reported OHRQoL, self-esteem or perception of orthodontic aesthetic treatment need or their child between malocclusion groups (Parent COHIP p = 0.2361; Parent CHQ-SE p = 0.9161; Parent IOTN-AC p = 0.3191). Comparing child/adolescents versus parents for each malocclusion, there was no significant difference in OHRQoL (II/1M p = 0.3110; II/2M p = 0.2317), self-esteem (II/1M p = 0.5585; II/2M p = 0.5) or perceived orthodontic aesthetic treatment need (II/1M p = 0.0645; II/2M p = 0.4050). Furthermore, there was no significant difference in family impact for children/adolescents with II/1M compared to those with II/2M (p = 0.3480). Increased age and female gender had a significantly negative impact on child-reported OHRQoL (p = 0.0001 and p < 0.0001, respectively) and self-esteem (p < 0.0001 and p = 0.0016, respectively), while female parent gender and SES i.e. those without medical cards, negatively influenced parent-reported OHRQoL (p = 0.0014 and p = 0.0450, respectively). SES influenced parent-reported self-esteem of their child (p = 0.0125), whereby those with medical cards reported worse self-esteem, while caries experience negatively influenced family impact (p = 0.0295). Younger age and having a medical card had a significantly negative impact on child reported perceived orthodontic aesthetic treatment need (p = 0.0365 and p = 0.0174, respectively). Child and parent perceived orthodontic aesthetic treatment need were significantly lower than clinician-reported (p < 0.05). Conclusions • There were no significant differences between II/1M and II/2M in relation to child-reported or parent-reported OHRQoL, self-esteem, perception of orthodontic aesthetic treatment need or family impact. • For each malocclusion, there were no significant difference between child/adolescent versus parent for all measures recorded. • Other variables, however, were found to impact perceptions, such as age, gender and SES. Increased age and female gender negatively impacted child-reported OHRQoL and self-esteem. Female parents and parents without medical cards reported worse OHRQoL for their child, while parents with medical cards reported worse self-esteem for their child. • Clinician-reported perceived orthodontic aesthetic treatment need was more severe than parent and child perceptions, regardless of malocclusion type.Item Surgical exposure of the unilateral palatally impacted canine – a mixed-methods investigation(University College Cork, 2024) Murphy, Claire.; Millett, DeclanAims: • To assess the volumetric palatal tissue changes that occur with open exposure under local anaesthesia of a unilateral palatally impacted canine (PIC). • To assess the patient pain experience in the first post-operative week following open exposure of a unilateral PIC. • To investigate if a relationship exists between severity of impaction of a unilateral PIC, operator perceived difficulty, duration of surgical procedure, volume of tissue removal and post-operative pain. • To assess the patient’s knowledge, understanding including perceived benefits and risks, attitude, experience and level of involvement in shared decision-making regarding open exposure under local anaesthesia of a unilateral PIC. Materials and methods: Following ethical approval, thirty adolescents referred to the Oral Surgery Department at Cork University Dental School and Hospital (CUDSH) for open exposure of a unilateral PIC were invited to participate in the study . All participants had a unilateral PIC exposed under local anaesthesia by the same Specialist Oral Surgeon. For the first week following surgery, all participants completed the short form McGill Pain Questionnaire (SF-MPQ) and a pain diary at specified time points. To assess the volume of tissue removal, intraoral scans were recorded using a Dexis IS3800W scanner pre- and intra-operatively. Scans were imported into Geomagic Studio software and converted to mesh files. These files were then aligned and a digital model of the excised portion was generated. Volumetric measurement of the excised portion was created using Rhino 3D software. Perceived surgical difficulty was assessed by the surgeon using a 100mm VAS and a surgical questionnaire. Surgical duration was also recorded. Orthopantomograms were used to assess the severity of canine impaction using the method of Ericson and Kurol (1988). Data from all variables were then compared individually to pain data. Relationships with post-operative pain were assessed using ANOVA models with SF-MPQ (Total) as the outcome variable, and separate ANOVA models were used for each of canine grading, operator perceived difficulty, surgical duration and volume of tissue removal, with p <0.05. Approximately 10 days post-operatively, one-to-one semi-structured interviews were undertaken with fifteen of the adolescents by a trained interviewer. Interviews were recorded, transcribed verbatim and subjected to interpretive phenomenological analysis (IPA) by QDA Ltd. (Dublin, Ireland) using NVivo software. Results: The mean volume of tissue removal with open exposure of a PIC was 0.193cm3 (SD 0.064cm3). Regarding severity of impaction, the mean sector was 3.1 and the mean alpha-angle was 38.06. The mean operator perceived difficulty was 11.98mm (SD 9.94mm). The average surgical duration was 9 minutes and 12 seconds (SD 0.11 minutes). Pain peaked the night of surgery, followed by an overall decline over the first post-operative week. No statistically significant relationship was found between patient perceived pain and any of the quantitative variables (volume of tissue removal p = 0. 1921; severity of impaction p = 0.6973; operator perceived difficulty p = 0.4635 and surgical duration p = 0.3859). The qualitative analysis found that participants had a good overall knowledge of the treatment process. They expressed high levels of satisfaction with the explanations provided regarding all aspects of the surgery. Participants initially felt nervous, but anxiety dissipated when provided with reassurance from the surgeon and after administration of the local anaesthetic. In general, participants were not well versed in the causes for impaction or the possible risks of leaving a PIC untreated. Regarding shared decision-making, participants felt involved in this, along with their parents and the operator. Surgery had a minimal impact on eating, speaking and other activities. Overall, participants had more positive than negative experiences. Conclusions: • The mean volume of tissue removed during open exposure of a PIC was less than 0.2cm3. • In general, pain peaked the night of the procedure, and then had an overall reduction in the first post-operative week. • No relationship existed between severity of impaction of a unilateral PIC, operator perceived difficulty, duration of surgical procedure, volume of tissue removal and post-operative pain. • Patients had varying levels of knowledge and understanding regarding open exposure of a PIC and felt pleased with their level of involvement in the shared decision-making.Item Diffuse reflectance spectroscopy in the identification of oral potentially malignant disorders(University College Cork, 2024) Fahy, Edward; Ni Riordain, Richeal; Burke, RayAims: Diffuse reflectance spectroscopy (DRS) examines the composition of tissue by analysing light reflected from inside the tissue. DRS has been applied to cancer diagnostics in liver, brain, breast and others. The aims of this study were to (i) to formulate a clinical protocol for use of DRS in diagnosis of oral potentially malignant disorder (OPMD), (ii) to explore the clinical utility for this probe in the mouth and (iii) to review the protocol and assess its potential use in clinical practice. Materials and Methods: A clinical protocol for use of the DRS probe was formulated based on literature review and clinical experience. A translational clinical research study with two groups, one with histologically confirmed OPMD (n=53) and a control group (n=27) were enrolled. All participants received DRS of mucosal surfaces, including areas of OPMD, in the mouth. The readings were then investigated to find reliable biomarkers and their accuracy to differentiate the two groups. Repeatability and reproducibility with two users were examined. Interviews were carried out with oral surgery clinicians after reading the protocol. Results: The protocol produced good results, which were grouped based on the site of acquisition. Our analysis found accuracy figures of 89% and 87% respectively for distinguishing OPMD and normal mucosa in the buccal mucosa and ventral tongue. This OPMD group was made up of mostly oral lichen planus (OLP), with small numbers of other diagnoses. (OLP n=41, oral leukoplakia n=5, others n=5) Accuracy figures for the dorsum of the tongue were poor. DRS was easy to use, quick and acceptable to patients. Repeatability was shown to be good, however reproducibility was fair. This may be due to inter-user pressure differences in the mouth. Clinicians were sceptical of this new technology, in part due to lack of evidence of clinical utility compared with biopsy. Conclusion: DRS has shown a new role in identifying oral lichen planus in the buccal mucosa and ventral tongue. This device may have poor accuracy in identifying oral lichen planus on the dorsal surface of the tongue. It has potential as a replacement for biopsy as a screening tool, however observed difficulties in clinical use preclude widespread implementation. Observed inter-user variability in the mouth has not been thus far explored in the DRS literature. Further studies are needed to confirm this observation.Item Benign, potentially malignant & malignant oral lesions; an analysis of oral and gut microbiota(University College Cork, 2024) Nayyar, Junaid; Brady, Paul; Ross, R. Paul; Stanton, CatherineIntroduction: The human microbiome is widely known to be associated with health and disease. The oral microbiome has been linked with oral diseases and infections, though not many studies have explored the relation between oral and gut microbiome with oral cancer based on their histology. This study explores the oral and gut microbiota in 30 participants (n=30) divided in to three groups based on histology; benign (B) (n=15), potentially malignant (PM) (n=8), and malignant (M) (n=7) oral lesions. Methods: Using shotgun metagenomic sequencing, we analysed the microbiota profiles to determine their potential as biomarkers for oral malignancy. We looked at alpha diversity, beta diversity, taxonomy, differential abundance, and functional profiling. Results: Our results showed distinct gut microbial profiles between benign and malignant groups and the association of specific microbes in oral saliva, such as Haemophilus parainfluenzae and Veillonella parvula with malignancy. The influence of factors such as smoking, alcohol and oral hygiene was also studied, with oral hygiene being the leading factor explaining the variance in oral and gut microbial composition. Conclusions: Our study suggests that oral and gut microbiomes could act as possible biomarkers and aid in early detection and assessment of oral cancer risk. Further research is required to develop definitive biomarkers in both potentially malignant and malignant oral lesions.Item An assessment of the oral health status and dental treatment needs of oncology patients receiving bone modifying agents(University College Cork, 2024) Byrne, Harriet; Ni Riordain, Richeal; O' Reilly, Séamus; University College CorkAims To assess the oral health status and dental care treatment needs of oncology patients receiving bone modifying agents (BMAs). Additionally, to explore barriers to dental care for this cohort of patients. Materials and Methods This was a mixed methods study conducted in 2 phases. In Phase 1, patients were recruited from the oncology clinics in the Cork University Hospital (CUH), South Infirmary Victoria University Hospital (SIVUH) and Mercy University Hospital (MUH). The oral health status and dental care needs were assessed using the Decayed, Missing and Filled teeth (DMFT) index, periodontal staging and grading classification (AAP) and their dental care requirements. Dental treatment was then completed to stabilise the oral health prior to commencing a BMA. Multivariate analysis was conducted to identify certain characteristics which may highlight added risk factors for dental disease and dental treatment needs. Phase 2 included focus group discussions with general dental practitioners alongside a focus group and qualitative interviews with patients to explore their opinions of the oncodental interface. Ethical approval was granted for a prospective, observational study by the Clinical Research Ethics Committee, University College Cork. Results In Phase 1, a total of 150 patients were assessed prior to a BMA. 70% (n=105) were female and 30% (n=45) were male, with a mean age of 61.5 years (SD 11.75 years). Breast cancer was the most common cancer amongst females (n=95) and prostate cancer amongst males (n=22). 94% (n=142) were planned for intravenous (IV) zoledronic acid and 6% (n=8) were planned for subcutaneous (SC) denosumab. 37 patients were current smokers (24.7%), and 23 patients were ex-smokers (15.3%). 65 patients (43.3%) did not have a general dental practitioner (GDP) at the time of presentation and 76 patients (50%) had a dental presenting complaint, where dental neglect (n=53, 35.3%) and functional issues (n=35, 23.3%) were the most common presenting complaints. The mean DMFT was 17.68 (SD 7.85) and 145 (97%) had periodontal disease. 20% (n=30) wore a denture, 9% (n=3) did not adequately fit and 16% (n=5) had clinical evidence of substandard denture hygiene. 86 restorations were placed and 188 teeth were extracted over the course of treatments. 121 teeth (64.4%) were extracted due to periodontal disease and 67 (35.6%) teeth were extracted due to dental decay. 82 teeth (95%) were restored due to primary decay and 6 teeth (5%) were restored due to secondary decay. 8 patients (5%) required an intraoral biopsy and dysplasia was reported in 2 patients. 7 patients (5%) required a new denture and 147 patients (98%) achieved dental fitness prior to BMA treatment. Multivariate analysis revealed a significant result for a periodontal extraction and increasing age, which increased by 21.2% every 10 years (p=0.0239). Patients who did not have a GDP were twice as likely to require dental restorations (OR=2.122) and required 67.5% more restorations. Patients that attended on an irregular (every 2-4 years) were 2.5 times and rare (5 years or more) basis were 3.4 times as likely to require an extraction compared to frequent attenders (OR=2.5 and OR=3.407), respectively. A current smoker was 3.4 times as likely to require an extraction, particularly due to periodontal disease (p<0.001). In Phase 2, 10 patients and 20 dentists were included in qualitative interviews. Data was collected until data saturation was achieved. Data were then transcribed and analysed using thematic analysis. Multiple themes emerged amongst dentists, including the difficulties of treatment planning for oncology patients planned for or receiving BMA, lack of guidance criteria to assist treatment planning, poor knowledge of medication-related osteonecrosis of the jaw (MRONJ) amongst general medical practitioners (GMPs), and management of these patients in the emergency setting. Patients expressed concerns about the additional burden of dental care, their lack of knowledge of MRONJ prior to their dental assessment, and the reassurance of a multidisciplinary co-ordinated dental service. Conclusion Our study highlights the vulnerability of this cohort of patients due to their dental care treatment needs. Dental disease is an integral factor for MRONJ, which must be addressed as a component of their overall oncology treatment plan.